RAJIVGANDHIUNIVERSITY OF HEALTHSCIENCE BANGALORE, KARNATAKA.
PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION
1 / NAME OF THE CANDIDATE AND ADDRESS / MS. SAMPA MANDAL1ST YEAR M.SC NURSING
THE OXFORDCOLLEGE OF NURSING
1ST PHASE, J.P.NAGAR,
BANGALORE 560078
2 / NAME OF THE INSTITUTION / THE OXFORDCOLLEGE OF NURSING
1ST PHASE J.P.NAGAR
BANGALORE 560078
3 / COURSE OF STUDY AND SUBJECT / DEGREE OF MASTER OF SCIENCE IN NURSING, MEDICAL SURGICAL NURSING.
4 / DATE OF ADMISSION TO COURSE / 31-05-07
5 / TITLE OF THE TOPIC / EFFECTIVENESS OF STRUCTURED TEACHING PROGRAMME ON KNOWLEDGE REGARDING ARTERIAL BLOOD GAS(ABG) ANALYSIS AMONG STAFF NURSES WORKING IN SELECTED HOSPITAL, BANGALORE.
6. BRIEF RESUME OF THE INTENDED WORK:
INTRODUCTION
Health is considered as one of the most important values in life. It is a key factor and is regarded as precious. Health as well as longevity should be protected and enhanced as much as possible. Early detection and treatment is one of the measures to prevent illness and also to reduce complications and death. Early diagnosis is key to better management1.
According to Hippocrates (460-377 BC) good health resides in a proper balance among the four humors: blood, phlegm, blackbile, and yellow bile, a balance that depends on the generationof life-giving heat within the left ventricle. Among these humors blood is very important as it plays a vital role in maintaining normal body mechanism2. The primary function of blood is to transport oxygen from the lungs to the body tissue and CO2 from the tissues to the lungs. This function is essential in order to prevent the death of tissues due to hypoxia.
Many life saving diagnostic tests which are performed in clinical set up to identify disease and are very essential tools in screening any deviations from normal functions of the body. The methods used will of course vary from assessment of radial pulse, blood pressure, and pulse oxymeter to the increasingly complex invasive hemodynamic monitoring such as interpretation of ABG sample with super specialization health care management in care of the patient. Though there are various diagnostic procedures, ABG analysis can be thought of as a window through which ventilation, respiration, metabolism and acid-base balance can be examined1.
Blood gas studies are concerned with repatriation of the exchange gases between the lungs and blood and between blood and tissues. The term blood gas strictly refers to the measurement of the tension or partial pressure of oxygen, CO2 and the estimation of H+ ion concentration or PH is an integral part of blood gas measurement. Arterial blood-gas (ABG) analysis is one of the most basic tests of pulmonary function, performed routinely in hospital inpatient floors and in intensive care units, pulmonary clinics, emergency departments, surgical suites, and pulmonary function laboratories throughout the world3. The measurement of arterial blood gases (ABG) has assumed an increasingly important role in the process of clinical evaluation, and has been widely used during the past three decades4.
Diagnostic utility of arterial blood gases for investigation of pulmonary embolism in USA (1997) has 76%5.The development and application of guidelines about ABG have become common practice in many Western countries6. According to studies performed in UK, 79% of patients will undergo arterial blood gas analysis on admission7. In Europe wide survey, 81%of patients with ventilatory frequency was routinely measured8. Mohamed Al-Moamary (1999) conducted a study on the appropriateness of ABG measurement found that total number of ABG requested were 60.2% from all medical wards, 13.3% from the surgical ward, and 22% from the cardiology department9.
Statistics revealed that ABG analysis were requested for 37.8% dyspnic clients, 13.1% for clients with liver and GI disorders, 10.2% for clients who had trauma or met with motor vehicle accidents, for clients with chest pain were 5.1%, 7% for clients with diabetes mellitus and 6.1% for clients who had cardiac arrest and 34.7% were of miscellaneous indications9. Mohan Alladi (2006) conducted a study predictors of outcome in patients with severe acute exacerbation of COPD requiring admission to ICU and concluded that ABG analysis revealed that 33.8% of patients had respiratory failure and 18.4% of patients were in need of mechanical ventilation10. Singh V.K (2006) conducted a study to identify the factors for predicting the outcome of ventilator patient with respiratory failure. Based on ABG findings they concluded that 52% of patients were hypoxemic and 48% of patients were hypercapnic11. Cheng Yu-Jen (2003) conducted a retrospective study to assess whether arterial blood gas analysis is helpful for deciding on the best management plan. Study concluded that ABG data can help to make the right decision about treatment12.
The utilization of minimally invasive techniques such as the analysis of an arterial blood sample will provide reliable and accurate values of gas tension with minimal discomfort and minim expenses, and will present clinical information, which may reduce hospitalization13.
6.1 NEED FOR THE STUDY
ABG measurements have been increasingly used in different medical conditions both in pulmonary and non-pulmonary disease conditions for accurate diagnosis14. Alteration in oxygen, carbon dioxide, pH, and HCO3- level leads to conditions like respiratory or metabolic acidosis or alkalosis. These conditions if not early diagnosed and treated may lead to several complications and may unable to restore normal health. Clients who manifest with hyper-metabolic states such as fever, sepsis, burns, client receiving total parenteral nutrition or enteral tube feedings high in carbohydrate, mechanically ventilated clients, clients with insulin- dependent diabetes mellitus, clients with vomiting, diarrhea or enteric drainage are subjected for ABG analysis15.
Nurses play an important role in early detection of high risk clients with acid base imbalance in critical care units. The nurses collaborate in the administration drug therapy, oxygen therapy and mechanical ventilation when indicated. In extreme circumstances in which therapeutic compensation is required, the nurse should be knowledgeable about potential risk of this therapy (drug, oxygen therapy) and able to carefully monitor administration rates and therapeutic responses16.
ABG offers insights into how a patient’s cardiovascular system and respiratory system are responding to acute physiologic changes. But if nurses do not have experience with it they may find difficult for its management. A clear and skillful observation and analyzing can prevent many fatal complications in an ill patient.
Nursing as a profession is now responsible to account for its competence and performance. This has seen the birth of the language of outcome. Outcome is mechanism to evaluate quality, improve effectiveness and link practices to professional accountability. ABG analysis requires skillful observations and careful analysis by competent nurses, which can prevent fatal complication in ill patients. The nurse plays an important role in monitoring the patient’s progresses. A nurse has to be competent and skillful in handling situations that will result in effecting the ABG analysis of the patients. A nurse has to make a decision which is beneficial to the client life. By carefully analyzing the nurse is able to recognize early causes and manage problems before they arise. When ABG analyses have been done properly the patient experience more rapid positive outcomes17.
Brokalaki H (2004) conducted a study about omissions and errors during oxygen therapy of hospitalized patients in a large city of Greece with the sample size of 105 head nurses working in several hospitals. The majority of the nurses (88.6%) stated that there was no protocol or teaching programme for oxygen therapy and it was not commonly guided by ABG analysis. Result indicated that educational programme, nursing protocols and guidelines are becoming mandatory in ABG analysis at country in order to ensure the proper use of oxygen therapy and nebulizers18.
Ganguly Sonali (2007) conducted a study about effectiveness of a need based teaching protocol on nurses responsibility in ABG analysis for the nursing personnel working in the critical care units. Findings of the study revealed that the teaching programme was effective and increasing the knowledge on ABG analysis as the computed “t” test was significant at 0.05 level. The nursing personal were motivated to learn and continuing nursing education is the key to up to date the knowledge of the nursing personal which will help to provide comprehensive nursing care19.
Majority of patients with ventilation as being monitored by ABG analysis in spite of continuous monitor with pulse oxymeter. Based on the above statistics and findings as well as the investigator’s clinical experience found that the nurses take an active part in collecting ABG samples, but their knowledge is inadequate in interpreting ABG reports. This motivated the investigator to select the present study. Therefore, the investigator felt that there is a need to develop structured teaching program for the nurses to improve and update their knowledge regarding ABG analysis and its interpretation which in turn increases their knowledge and practice.
6.2REVIEW OF RELATED LITERATURE
Review of literature for the study has been organized underfollowing headings.
6.2.1Review related to the general information about ABG analysis
6.2.2Review related to the nurses knowledge about ABG analysis
6.2.3Review related to the effectiveness of structured teaching programme
6.2.1 Review related to the general information about ABG analysis.
An article on interpreting arterial blood gases: easy as ABC, describes the interpretation of step-by-step approach of oxygenation ventilation, and acid-balance. With practice nurses can improve skill and accuracy at ABG interpretation17.
Amith Banga (2006) conducted study in India, common acid base disorders are respiratory acidosis (RA) and metabolic acidosis (MA).Among the patients who had acidosis, mortality was higher for patients with metabolic acidosis (75%) than those with respiratory acidosis (52%)20.
An article on blood gases analysis in mechanically ventilated patients. Measurement of blood gases and pH are widely used as an investigation to screen pulmonary function for pre operative, intra operative, post operative and life saving management (e.g. Ventilatory support) are based on blood gas and pH values21.
Dr. Sunitha Ugramurthy (2004) conducted a study and reports that ABG are usually measured by obtaining blood sample by arterial puncture. In certain situations arterial puncture may not be feasible like in cases of coagulation disorders, anticoagulant therapy, presence of arterial graft etc. In such Situation blood sample collected from arterialized great toe by means of pre heparinised capillary tubes can be a good substitute for arterial blood provided there is no circulatory shock22.
Kenneth P (2001) conducted a study on Arterial Blood Gas and pulse oxymetry in initial management of patients with community acquired pneumonia. The study revealed that in the initial management of community acquired pneumonia, ABG analysis can be used widely 23.
Winterhalter M (2000) conducted a study on changes of arterial blood gas analysis with post-operative cardio-thoracic-surgery patients who are in need of artificial respiration over a short period of transport time. The ABG analysis revealed that the patients after extended cardio- thoracic surgery required post- operative ventilation during the transport from the operating theater to the intensive care unit24.
Morinaka S(1998) conducted a study about arterial blood gas abnormalities in patients with dizziness and found that 50% showed ABG abnormalities in the dizziness period. Study findings suggested that ABG abnormalities cause temporary vestibular dehabituation that increases the frequency of dizziness25.
Hamdan Al-Jahdali (1999) conducted a study to observe utilization of ABG measurements. During the study period of two weeks, 98 ABG sample were requested from adult patients (acute care general wards). The researcher summarized that ABG measurements from acute care wards in a tertiary-care teaching hospital were found to be utilized more9.
Franklin.M.L (1996) conducted a study on the evaluation of an on-demand, bedside blood gas monitor on pulmonary artery blood gas determinations on critically ill patients often having cardiopulmonary disturbance and who required rapid and frequent assessment for optimal care, cardiac output determinations and arterial blood gas analysis. The study suggested that the blood gas monitoring provided rapid and accurate determinations of arterial blood gases allowing optimal therapeutic interventions in critically ill patients26.
M M Shabot (1990)conducted a study about decision support alerts for clinical laboratory and blood gas data. It states that half of all critical alerts were detected caused by altered blood gas values from amongst approximately 115,000 laboratory data27.
6.2.2 Review related to the nurses knowledge about ABG analysis.
Dodds S (2007) reports that assessments for long-term oxygen therapy are now being undertaken by nurses. The key skill required is arterial blood gas sampling. This has traditionally been the role of the doctor, however by using an education and training package along with a competency-based assessment, nurses can now perform this extended role. Findings stated that competency-based education and training programme is useful for nurses to carry out ABG analysis procedure 17.
Linda Ruholl (2006) conducted a study about ABG analysis and nursing responses and concluded that the nurse can improve blood gas interpretation skills by practicing with blood gas sample. That helps analysis and guides appropriate nursing interventions28.
Maag M.M (2005) conducted a study on arterial blood gas (ABG) interpretation for health care professionals and stated that arterial blood gas analysis is a critical skill required by the nurses in order to provide safe and competent patient care. Nursing interventions focus on maintaining patient alveolar exchange of CO2 or O2 by analyzing arterial blood gas concentration. The results indicated that the teaching programme promoted better understanding by the health care professionals about ABG analysis and aided in the application of knowledge in the clinical setting 29.
An article on the audit of the patient’s experience of arterial blood gas testing cited that arterial puncture is the most common method used to obtain a sample for the measurement of arterial blood gas and is essential to guide the prescription of long-term oxygen therapy in patients with chronic hypoxic lung disease. The respiratory nurse specialist takes an ideal position to implement changes to improve the patient's experience of chronic disease management 30.
6.2.4Review related to the effectiveness of structured teaching
Programme
Qureshi A.K (2004) conducted a study about effectiveness of an emergency preparedness training program for public health nurses in New York City. The program focused on the basic public health emergency preparedness competencies and the emergency response role of public health workers employed by the New York City School Department of Health and Mental Hygiene School Health Program. The evaluation methods included pre -testing followed by a repeat post-test one month after the program. The program resulted in positive shifts in both knowledge and emergency response attitudes and proved that frequent and timely interventions can improve the efficacy of the public health nurses31.
Frutiger A (1993) conducted a study to describe structure and function of a computerized based blood gas interpretation program developed for nurses and physicians, and to test educational impact and user acceptance .The results have shown that exposure to the ABG-consultant has increased the blood gas knowledge of the ICU nurses32.
Garcia ML (2000) conducted a study to evaluate the effectiveness of an HIV training programme for obstetric nurses at a managed care organization. Pregnant women who received prenatal care after the nurses attended the programme were more likely to be tested than women who received prenatal care before the nurses who were trained (96% versus 48%).The training programme resulted in the increased number of high risk women being tested (94% versus 60%) which proved the effectiveness of the training programme given to the nurses33
STATEMENT OF THE PROBLEM
A study to assess the effectiveness of Structured Teaching Programme on knowledge regarding ABG(Arterial Blood Gas)analysis among staffnursesworking in selected hospital, Bangalore.
.
6.3.OBJECTIVES OF THE STUDY
6.3.1 To assess the knowledge of staff nurses regarding arterial
blood gas analysis in terms of pre test knowledge score.
6.3.2 To administer a structured teaching programme on arterial
blood gasanalysis among nurses.
6.3.3 To determine the effectiveness of structured teaching
programme bycomparing the pre and post test knowledge
score.
6.3.4 To find out the association between knowledge score with
selected demographic variables.
6.4 HYPOTHESES OF THE STUDY
The study attempted to examine the following hypothesis
H1: There will be significant differencebetween the pre and
posttestknowledge score of staff nurses regarding ABG
analysis.
H2:There will be significant association between knowledge
score withselected demographicvariables.
6.5 VARIABLES UNDER THE STUDY
Independent variable
Structured teaching programme on ABG analysis.
Dependent variable
Knowledge regarding ABG analysis.
6.6OPERATIONAL DEFINITIONS
Effectiveness: refers to the extent to which the planned
teaching program on ABG (Arterial Blood Gas) analysis
achieves desired effectin improving the knowledge of staff
nurses as evident from gain in knowledge scores.
Knowledge: refers to correct responses from the staff nurses
aboutABG Analysiselicited through Structured Knowledge
Questionnaire.
Structured Teaching Programme: refers to planned
instructional material regarding systematic ABG analysis and its
interpretation.
Arterial Blood gas: refers to a life saving diagnostic procedure
todetermine O2, CO2, HCO-3,PH balance and related
abnormalities.
Staff nurses: refers to an individual who is qualified as a
registerednursesworking in selected hospital.
6.7 ASSUMPTIONS
- Nurses may have some knowledge regarding ABG analysis
and itsinterpretation.
- Nurses may have interest to know more about ABG analysis
and its interpretation
7.0 MATERIAL AND METHODS
7.1 SOURCES OF DATA
The data will be collected from the staff nurses in selected
hospital,Bangalore.
7.2METHODS OF COLLECTION OF DATA
Structured self reporting technique will be used to collect the